Burton Tina M, Luby Marie, Nadareishvili Zurab, Benson Richard T, Lynch John K, Latour Lawrence L, Hsia Amie W
From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD.
Neurology. 2017 Jul 25;89(4):343-348. doi: 10.1212/WNL.0000000000004149. Epub 2017 Jun 28.
To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis.
This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)-treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time.
Of the 725 thrombolysis-treated patients, 29% were at spoke hospitals and 71% at hubs. Spoke hospital patients differed from hubs by age (mean 62 ± 15 vs 72 ± 15 years, < 0.0001), risk factors (atrial fibrillation, 17% vs 32%, < 0.0001; alcohol consumption, 9% vs 4%, = 0.007; smoking, 23% vs 13%, = 0.001), and mimics (16% vs 0.6%, < 0.0001). Inclusion of mimics resulted in better outcomes for spokes vs hubs by mRS ≤1 (40% vs 27%, = 0.002), parenchymal hematoma type 2 (3% vs 7%, = 0.037), and discharge home (47% vs 37%, = 0.01). Excluding mimics, there were no significant differences. Comparing epochs, spoke stroke mimic rate doubled (9%-20%, = 0.03); hub rate was unchanged (0%-1%, = 0.175).
Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.
确定卒中疑似病例在多大程度上影响临床结果以及错误的卒中诊断可能产生的影响。
这项对2005年至2014年数据的回顾性分析纳入了接受静脉注射组织型纤溶酶原激活剂（tPA）治疗、临床怀疑为急性缺血性卒中且被转诊或直接收治到我们两家中心医院的成年患者。主要结局指标比较了基于CT的基层医院和基于MRI的中心医院的疑似病例发生率、出血性转化、随访改良Rankin量表（mRS）评分以及出院处置情况。次要结局指标则进行了时间上的比较。
在725例接受溶栓治疗的患者中，29%在基层医院，71%在中心医院。基层医院患者与中心医院患者在年龄（平均62±15岁对72±15岁，P<0.0001）、危险因素（心房颤动，17%对32%，P<0.0001；饮酒，9%对4%，P=0.007；吸烟，23%对13%，P=0.001）以及疑似病例发生率（16%对0.6%，P<0.0001）方面存在差异。纳入疑似病例后，基层医院在mRS评分≤1（40%对27%，P=0.002）、2型实质血肿（3%对7%，P=0.037）以及出院回家（47%对37%，P=0.01）方面的结局优于中心医院。排除疑似病例后，无显著差异。比较不同时期，基层医院的卒中疑似病例发生率翻倍（9% - 20%，P=0.03）；中心医院的发生率未变（0% - 1%，P=0.175）。
在我们基于CT的基层医院，卒中疑似病例的溶栓治疗正在增加，而基于MRI的中心医院则没有。当出院时的卒中诊断不明确时，在基于大型卒中数据库解释临床结果时应谨慎。将接受治疗的卒中疑似病例误报为卒中会人为提高总体良好临床结局，但会给患者和医疗保健系统带来额外的下游成本。
